Port Nelson Limited Application Form

Port Nelson Limited Application Form

Surname:______First Name: ______

Street Address: ______

______

City: Postal Code: ______

Home Number: ______Work Number: ______

Mobile Number: ______Email: ______

Position Applied For: ______

If you are making a general enquiry about work, what areas are you interested in?

Please tick appropriate boxes.

StevedoringICT Marine

SecurityHuman Resources Workshop

Finance & AdminDrivers ie. Crane, Forklift Logistics

Any specific roles you are interested in within these areas:

Office Use Only

Resident Status

Are you legally entitled to work permanently in New Zealand?YESNO

If not, for what length of time are you entitled to work in New

Zealand? (please attach evidence)______

Drivers Licence

Do you hold a current NZ Drivers Licence?YESNO

If yes, what class(es)?______

Do you have any licence restrictions? YESNO

If yes, please list ___

Have you ever been disqualified from driving?YESNO

If yes, why?______

Do you have any current demerit points against your licence?YESNO

If yes, how many? ______

What other types of licences do you hold? ______

Criminal Convictions

Have you been convicted of a criminal offence or have a court case

that is, or could be pending? YESNO

If yes, please detail:______

We undertake criminal conviction history checks for all appointments.

You are required to provide your approvalto access your criminal

convictions history from the Ministry of Justice. Are you agreeable to this? YES NO

______

Medical

Have you had an injury or medical condition caused by gradual process,

disease or infection, such as repetitive strain injury, that the tasks of this

job may aggravate or contribute to? YESNO

If yes, please detail: ______

Have you ever suffered from a back injury or back strain that the tasks of

this job may aggravate or contribute to? YESNO

If yes, please detail: ______

Are you aware of, or being treated for, any current or former medical or health

related condition, illness, injury or disability that may affect your ability to carry

out the requirements of the job applied for or that may be aggravated or further

contributed to by the tasks of the job?YES NO

If yes, please detail: ______

______

You will be required to undertake a pre-employment medical examination

that tests for drugs, alcohol, vision and hearing. Are you agreeable to this?YESNO

(costs to be met by Port Nelson Ltd)

To be successful in your application for employment with Port Nelson Ltd the

checks/tests must be completed to Port Nelson Limited’s satisfaction. The

information gathered from the assessmentswill be used by Port Nelson Limited

solely for the purpose of determining your suitability for the role.

Secondary Education

School: / Location: / Period of Attendance:
Qualification Received: (if qualification not gained, please list classes passed)

Tertiary Education

Institution/Polytechnic: / Location: / Period of Attendance:
Qualification Received: (if qualification not gained, please list papers passed)

Other Qualifications(e.g. Forklift license; marine tickets, trade certificates)

Employment History

Please attach/provide a CV or complete the following information.

Please list your employment history starting with your most recent or current job and work back-wards through your career.

Start Date: / Finish Date: / Current Employer’s Name & Location: / Nature of Business:
Position Title
Current Salary: / Reason for Leaving:
Start Date: / Finish Date: / Employer’s Name & Location: / Nature of Business:
Position Title
Reason for Leaving:
Start Date: / Finish Date: / Employer’s Name & Location: / Nature of Business:
Position Title
Reason for Leaving:

References

Please provide two of your most recent business referees.

Reference 1:

Name: Company: Position:

Years Acquainted: Contact Details:

Reference 2:

Name: Company: Position:

Years Acquainted: Contact Details:

Hours & Days

Are you available for shiftwork (different hours / days) YESNO

What days and hours are you available to work?

Please tick where appropriate.

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Dayshift
Nightshift

What type of working arrangement are you looking for?

Please tick where appropriate.

Permanent Full Time Casual

Permanent Part TimeFixed Term

Any

General

Have you ever had a dispute with an employer, or been subject to disciplinary action, or have disciplinary action pending by an employer? YES NO

If yes, please detail:

Have you ever worked for PNL before?YESNO

If yes, please detail including reason for leaving:

What are your salary or hourly wage expectations?

When would you be available to commence employment?

Disclosure of Interest

Do any members of your family (including your partner or spouse) workfor Port Nelson Ltd?

YESNO

If yes, please detail:

Do you currently undertake secondary employment or plan to undertakeSecondary employment while employed at Port Nelson Ltd? YES NO

If yes, please detail:

Why are you looking to join Port Nelson Ltd? Please detail:

The facts set out by me in this application are true to the best of my knowledge and belief. I hereby authorise my former employers and referees to give any information regarding my employment with them, and in addition, to furnish any other information they may have concerning me. I understand that misrepresentation or omission of factual information on this application is cause for dismissal. I also understand that any false information given in relation to my medical history may result in loss of entitlement for any compensation from ACC.

I acknowledge and understand that in accepting employment from Port Nelson Ltd, I will comply with the Company’s various policies and procedures including the Drug and Alcohol testing programme.

In making this application, I warrant that:

• All representations or statements I have made to the Employer in making application for the employment are true and correct;
• I have not deliberately failed to disclose any matter that may have materially influenced the Employer’s decision to employ me;
• I do not have any contractual commitments that would conflict with the performance of my duties and obligations in the position.

SignedDate

Pre-employment check - request for ACC claims history

Please Read: Please complete this form and then email it to . Please provide a valid proof of identification: These include but are not limited to; Driver’s Licence, Passport, 18+ Card, Birth Certificate, or Statutory Declaration signed by the Police or JP.

Employers and recruitment agencies: unless the job applicant gives specific permission, the claims history provided will not include information about any:

• mental injury as a consequence of physical injury claims
• declined claims including accredited employer claims
• treatment injury claims
• claims occurring more than 10 years ago
• sensitive claims
• wilfully self-inflicted claims
• accidental death claim dependants

Part A: iDENTIFYING DETAILS

1. JOB APPLICANT’S details / PLEASE COMPLETE ALL SECTIONS
First Name: / Middle Name:
Surname: / Also known as (e.g Maiden name):
Date of Birth: / Phone Number/s:
Ethnicity: / Male Female
Mailing address: / Suburb :
Town/City: / Postal Code :
Previous Address: / Type of work/Industry:
2. employer OR RECRUITMENT AGENCY DETAILS / FOR ACC CLAIMS HISTORY RESULTS TO BE SENT TO
Organisation Name: Port Nelson Ltd / Contact Person’s Name: Suzanne Thompson
Contact Phone Number: 03 539 3828 / Contact Email Address:

Part B: CONSENT FOR ACC TO RELEASE INFORMATION

3. JOB APPLICANT’S CONSENT and signature
I authorise ACC to release my ACC claims history to the employer or recruitment agency named in Part A:2, and understand that I will be sent a copy to the mailing address marked in Part A:1.
I understand that this information will only be used to decide whether I can carry out the job safely.
I understand I have the right:

• to see and correct this information under the Privacy Act 1993
• that the employer or recruitment agency will use this information responsibly, and comply with the Privacy Act 1993, Health Information Privacy Code 1994 and the Human Rights Act 1993
• that the employer or recruitment agency will destroy the information once the job application process is complete.

Job applicant’s signature: / Date: